333.4 📋 章末速記 Summary

333.4.1 🔑 一句話總結

AKI = 短期內 (hours-days) 腎功能急速下降；KDIGO 2012 criteria：(1) Cr ↑ ≥ 0.3 mg/dL within 48 h，或 (2) Cr ↑ ≥ 1.5× baseline within 7 d，或 (3) UO < 0.5 mL/kg/h × 6 h；staging 1-3 based on Cr fold change + UO；etiology 三大類：(1) pre-renal (50-60%) — hypovolemia, low CO, NSAID, ACE, HRS — FENa < 1%, BUN/Cr > 20, U Osm > 500, hyaline casts；(2) intrinsic (20-30%) — ATN ischemic/toxic (aminoglycoside, vanc, contrast, cisplatin) — FENa > 2%, isothenuric, muddy brown granular casts; AIN (drugs PPI/NSAID/ICI — WBC casts + eosinophils); GN (RBC casts); vascular (TMA)；(3) post-renal (10-15%) — obstruction → hydronephrosis on US；workup：history + exam + UA + urine electrolytes (FENa, FEUrea on diuretics) + imaging (renal US first-line) + immunology + biomarkers (NGAL, KIM-1, Nephrocheck TIMP-2 × IGFBP7 FDA approved)；specific causes：HRS → terlipressin + albumin (FDA 2022, CONFIRM trial), liver transplant cure；rhabdomyolysis CK > 5000 → aggressive IVF + urine output > 200-300 mL/h；TLS → rasburicase + hydration；CA-AKI (contrast) → hydration prevention, incidence lower with modern contrast；ICI-associated AIN → hold ICI + steroids。

333.4.2 💊 治療精要

• pre-renal：address cause (volume, cardiac output, hold offending drugs) + IV fluids
• ATN：supportive, watch for fluid/electrolyte/uremia; many resolve in 1-3 weeks
• AIN：hold offending drug + steroids if severe / persistent
• post-renal：decompression (foley, ureteric stent, nephrostomy) + watch post-obstructive diuresis
• HRS：terlipressin + albumin (CONFIRM 2021, FDA 2022) or norepinephrine + albumin (ICU) + liver transplant
• rhabdomyolysis：aggressive IV fluids (normal saline) + urine output > 200-300 mL/h; alkalinization debated
• TLS：allopurinol (low risk) or rasburicase (high risk: AML/ALL/lymphoma) + hydration + monitor electrolytes
• CA-AKI：hydration (isotonic saline IV peri-procedure) + minimize contrast + avoid nephrotoxins
• ICI nephritis：hold ICI + prednisone 1 mg/kg → taper

333.4.3 🎯 盧醫師的考前提醒

1. KDIGO 2012 AKI 三標準必背：Cr ↑ ≥ 0.3 in 48 h、Cr ↑ ≥ 1.5× baseline in 7 d、UO < 0.5 mL/kg/h × 6 h；任一即診斷
2. KDIGO staging 1-3 by Cr fold change (1.5-1.9 / 2.0-2.9 / ≥ 3 OR Cr ≥ 4 OR RRT) + UO duration
3. pre-renal 經典 4 數據：FENa < 1%、BUN/Cr > 20、U Na < 20、U Osm > 500；reversible with volume
4. ATN 4 數據：FENa > 2%、BUN/Cr < 20、U Na > 40、U Osm 300-350 isothenuric + muddy brown granular casts classical
5. AIN diagnostic clues：WBC casts + urine eosinophils (Hansel stain, low sensitivity) + drug history (PPI, NSAID, penicillin, ICI, sulfonamide) + sometimes rash/fever/eosinophilia
6. post-renal AKI 需 bilateral 或 solitary kidney with obstruction；renal US first-line to detect hydronephrosis
7. HRS 治療 FDA 2022 breakthrough：terlipressin (CONFIRM trial) + albumin — first FDA-approved；alternative norepinephrine + albumin in ICU；liver transplant 是 cure
8. rhabdomyolysis AKI：CK > 5000 = high risk；myoglobin tubular obstruction + heme oxidative；aggressive IV fluids → urine output > 200-300 mL/h target
9. TLS prevention：high-risk (AML, ALL, high-burden lymphoma) → rasburicase (recombinant urate oxidase, contraindicated in G6PD)；low-risk → allopurinol + hydration
10. contrast-associated AKI 觀念更新：modern low/iso-osmolar contrast 風險較低；hydration is mainstay prevention；statins + NAC 證據有限；AMACING trial 顯示 low-risk patients 可能不需 routine hydration